Rainbows Ireland Participant Application Form for

Parental Separation/Divorce - Primary

*Effective from November 2019

Important Information for Parents to consider before completing this application form

The Rainbows service is an inclusive service open to children and young people experiencing grief and
loss resulting from bereavement/parental separation/parental relationship breakdown/divorce.

• Rainbows provides peer group support for children and young people experiencing grief and loss
as a result of bereavement and parental separation. Rainbows is a listening service only.
Rainbows is not a counselling service. Attending the programme provides children and young
people with an opportunity to meet with other children and young people of a similar age and
loss experience. No notes/diagnosis/ analysis/advice is undertaken. It is not an individual one to
one programme.

• It is Rainbows policy in parental separation/relationship breakdown that children and young

people need to be aware of the decision to separate and experience the impact of this decision
for a minimum period of 3 months before attending a programme. It is not necessary that any
formal legal proceedings have commenced.

• It is Rainbow policy that the signature of both parents is required for their child to attend the
programme. See page 6 for when this is waived.

• The Rainbows programme is not a preparation for an impending decision to separate or divorce.

• Rainbows Ireland makes every effort to support parents enrolling their child in the Rainbows
programme to make an informed decision on the suitability of the service for their child/children
and young people.

• Parents/guardians are strongly advised that the group support of the Rainbows programme is
not suitable for all children and young people at all times.

Some parents make an informed decision that the peer group support being offered as part of the
Rainbows Service, will not suit their child/children and young people at a particular time. Group
support does not suit all children and young people at all times. Sometimes this only becomes
apparent following the commencement of the programme. Rainbows reserves the right to make a
decision when these circumstances apply.

• Parents may be contacted during or after the programme if the programme may not be meeting
the needs of a child as a particular time.

• Or following completion of the programme, parents/guardians may be advised to contact their

GP for further advice.

For office use only:

Date of Application:

1
 Participant Information:

Name
Address:

Date of Birth

Class Level
Teacher
(Applicable to school
based prog. only)

Parent/Guardian Information:

Social Worker/Foster
carer*for children and
Parent /Guardian Parent /Guardian
young people on full
care orders.
Name

Postal Address

Mobile Number

Email
Address

Consent to be
contacted by
Rainbows
National Office**

*In relation to children and young people on voluntary care or interim care orders, consent of
parents is required.

**Please tick this box only if you consent to be contacted by Rainbows Ireland National Office by
email. Rainbows Ireland is funded by TUSLA, in order to continue receiving funding Rainbows
Ireland has to be able to show that we are valuable service. We may contact you to evaluate how
beneficial you found the programme for you child/children and young people.

In compliance with data protection, your contact details are for use by Rainbows Ireland and their agents
only and will not be passed on to any third party organisations. You may “opt out” to receiving such
information at any future time.

All information and documentation concerning this application can be shared with employees and
agents of Rainbows Ireland.

2
Personal information:

Circle the relevant option and complete further information in writing as required.

Has your child attended Rainbows before? Yes No

If ‘yes’, when? _____________________________________________________________

Where did they attend Rainbows previously? ______________________________________

Separation Loss:

Groups for separation and divorce

The Rainbows programme focuses on the identification and expression of feelings and not on
individual losses. As a result of this process, participants may meet, among others, many different
situations and arrangements including: children and young people living in two homes, children and
young people under supervised access with a parent, children and young people living with
grandparents, children and young people in joint custody arrangements, parents living in the same
house but separated, children and young people in step families, children and young people with
same sex parents, children and young people whose parents are separated and one of them in
prison, children and young people in voluntary or State care.

Please tick that you have read this information

Other Information:

Has your child attended any other service in relation to their loss? Yes No

If yes, what was the service and the nature of the service?

__________________________________________________________________________________

__________________________________________________________________________________

Please note that children and young people cannot be attending two services at the one time and
that there is a general 3 month time frame between children and young people attending
Rainbows after other supports.

Please tick to confirm that your child is no longer attending any additional service connected with
the parental separation at the time of this application.

Does your child have any additional needs that the Rainbows team needs to be aware of while they
are attending the group sessions? Yes No

Please note that volunteers will not be in a position to administer any form of prescribed medication.

3
If yes, please specify any issue that needs to be brought to the attention of the Rainbows team for
the duration of your child’s attendance on the programme.

__________________________________________________________________________________

__________________________________________________________________________________

__________________________________________________________________________________

Is there anything else that you would like us to know about your child?

__________________________________________________________________________________

__________________________________________________________________________________

__________________________________________________________________________________

Emergency Contact Information:

Please provide the names of two people, agreed by both parents/guardians, who can be contacted
in either parents/guardians unexpected absence or in case of emergency:

Emergency Contact 1 Emergency Contact 2

Name

Mobile
Number

Please provide names and numbers of 3 people, other than the parents/guardians who have
permission, from both parents, to collect your child from each session. Your child will only be
permitted to leave if one of the three named people below.

Person 1 Person 2 Person 3

Name

Mobile
Number
Relationship
to your
child

4
Please read all statements below and tick all boxes to confirm that you have read and
understood each statement.

Statement Please tick

I request a place for my child on the Rainbows programme.

I understand the programme is to facilitate listening support in relation to parental

separation and divorce i.e. that Rainbows is not professional counselling.

I understand that the programme is for children and young people who have been
made aware of the decision to separate and that it is suitable only when the impact of
that decision has been experienced in the life of a child for a minimum of three
months.

I have discussed with my child the purpose of attending the Rainbows programme.

My son/daughter has agreed to participate in the programme.

I understand that Rainbows cannot control, limit or restrict in any way what is shared
by participants in a group.

I understand that specific feedback is not given on my child’s participation in the

Rainbows programme.

I understand that any Rainbows materials used by my child are part of the programme
and are not available to a child to be brought outside the group on programme
conclusion.
I understand that Rainbows Ireland has made every effort to inform me, as a
parent/guardian, of the scope and limits of the service and thus cannot be deemed
responsible for needs that cannot be met by attending the programme.
I understand that all the Rainbows Programmes adhere to the Child Protection Policy
and Procedures, in accordance with Children and young people First: National
Guidance for the Protection and Welfare of Children and young people 2017

I understand participation in the Rainbows programme is not to be utilised or relied

upon in relation to court or other family law proceedings.

5
Final Declaration:

Please read, tick and confirm that you agree with the following:

I understand that this form is not a guarantee of a place on the programme for my child and that
the peer group support depends on sufficient numbers (minimum 4 per group) of a similar age
being available to form the groups.

The signature of both parents is normally required, unless the other parent is not a legal guardian.

Rainbows Ireland do not accept any responsibility for any dispute in this matter between parents.

The need for both signatures is waived under the following circumstances:

Please tick as required:

A court order – that dispenses with the consent of one parent.

Please attach a copy to this form in an envelope marked ‘Private’.

Parent/Guardian uncontactable, either directly or indirectly, or whereabouts unknown or where they

have failed upon request to provide an objection (presumed consent for the duration of the
programme)

I understand that this form and any other attached documents, may be made available to either
parent if requested, in joint custody/guardianship situations. Rainbows will provide such
information without further consultation.

I ___________________________________ certify that all information is true and accurate and I

understand that I am solely responsible for the information on this form.

Signed: __________________________________________

All sections of this form must be completed in full for this application to be considered for a place on
the programme.

Rainbows Ireland cannot be held responsible for any false declarations made on this application.

Signature: _______________________________________ Date: ____________________

Signature: _______________________________________ Date: ____________________

6
Dear __________________________,

I would like to enrol __________________________________________________________

in the Rainbows Programme. It is group support for children and young people whose
parents have separated and they meet other children and young people in a similar
situation.

The 9 week programme is being run in ___________________________________________

starting on ______________________and will run until ____________________________.

I am finalising the application and hope that you are agreeable

to_______________________________________________ participating in the programme.

If you are not in agreement with _______________________________________ attending

the programme, please notify me by________________(insert date), in writing to this
address:
___________________________________________________________________________
___________________________________________________________________________
___________________________________________________________________________

If nothing is received in writing to indicate that there is no agreement on this matter by

________________ (insert date),
I will confirm to the Coordinator that we are both in agreement on this.

Signed: _________________________________________

Date: ________________________